Bradycardia and congestive heart failure associated with ocular timolol maleate

A case of timolol-associated heart failure in a 73-year old white man is reported. The patient, with a history of cardiovascular disease and glaucoma, was admitted to the hospital because of complaints of shortness of breath, orthopnea, and reduced exercise tolerance. Chest roentgenogram showed interstitial congestive failure, and an EKG demonstrated sinus bradycardia. The patient's medications before admission included quinidine, isosorbide dinitrate, dipyridamole, aspirin, pilocarpine eyedrops 4%, timolol eyedrops 0.5%, and nitroglycerin ointment and sublingual tablets. On the second day of hospitalization, it was noted that the patient's dyspnea and sinus bradycardia could be related to a recent increase in his timolol dosage. The timolol was discontinued, and the patient's heart rate increased. As the patient's pulse rate increased, the symptoms of congestive heart failure disappeared. This case demonstrated the importance of obtaining complete drug histories from patients. The potential for adverse system reactions resulting from topical medications should be considered.